# PRO DENTAL MI 1 PC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Destiny Dental of Pontiac
- **Organization subpart:** No

## Provider details

- **NPI number:** 1063249332
- **Authorized official:** SIMONE WILSON-ADELEKE MPA-PPA (DIRECTOR OF CREDENTIALING)
- **Authorized official phone:** (732) 731-8398

## Contact information

- **Practice address:** 1101 E WALTON BLVD STE 300, PONTIAC, MI 48340-1590
- **Practice address phone:** (248) 499-9989
- **Practice address fax:** (248) 481-9896
- **Mailing address:** 10 WOODBRIDGE CENTER DR STE 520, WOODBRIDGE, NJ 07095-1152
- **Mailing address phone:** (732) 731-8398

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | — | — | Yes |

## Other

- **Enumeration date:** 09/19/2024
- **Last updated:** 09/19/2024